Clinical evaluation of tibiocalcaneal arthrodesis with retrograde intramedullary nail fixation in diabetic patients.

OBJECTIVE: The aim of this study was to evaluate clinical and functional outcomes in diabetic patients undergoing tibiocalcaneal arthrodesis using a retrograde nail. METHODS: A total of 12 diabetic patients [8 men and 4 women; mean age at intervention: 56.8 years (range: 27-76 years)] who underwent tibiocalcaneal arthrodesis by a retrograde nail were enrolled in this study. The indication for surgery was massive talar osteonecrosis in four patients, Charcot arthropathy in another four patients, and various severe ankle/hindfoot derangements in four patients. All surgeries were performed by the same surgeon. All patients were evaluated by their American Orthopedic Foot and Ankle Score (AOFAS) score, and radiographic follow-up was performed. RESULTS: The mean follow-up time was 59.5 months (range: 27-121 months). Ten patients (83.3%) healed and were able to walk with full weight bearing without crutches. Among them, nine patients (75%) achieved union with solid bone healing. The mean overall improvement in the AOFAS score was 72.5% (preoperatively: 40 points vs postoperatively: 69 points; p<0.001). We observe a complication in 50% of our patients. Minor complications included two cases of dehiscence of the surgical wound, one case of soft tissue irritation owing to hardware protrusion, and one cause of lymphedema. Two patients had deep infection and underwent surgical removal of hardware, debridement, and antibiotic treatment: one healed after the treatment but never recovered full weight bearing and the other one died from other complications. These two deep infections occurred after 23 months of follow-up. CONCLUSION: Tibiocalcaneal arthrodesis using retrograde nails is a salvage technique extremely effective in ankle and hindfoot disorders in a diabetic patient. This procedure allows good functional outcomes and pain relief. When correctly indicated, it is a safe procedure with good clinical outcomes and low risk of below-knee amputation. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Postoperative weightbearing following ankle arthrodesis: a systematic review.

AIMS: Postoperative rehabilitation regimens following ankle arthrodesis vary considerably. A systematic review was conducted to determine the evidence for weightbearing recommendations following ankle arthrodesis, and to compare outcomes between different regimens. PATIENTS AND METHODS: MEDLINE, Web of Science, Embase, and Scopus databases were searched for studies reporting outcomes following ankle arthrodesis, in which standardized postoperative rehabilitation regimens were employed. Eligible studies were grouped according to duration of postoperative nonweightbearing: zero to one weeks (group A), two to three weeks (group B), four to five weeks (group C), or six weeks or more (group D). Outcome data were pooled and compared between groups. Outcomes analyzed included union rates, time to union, clinical scores, and complication rates. RESULTS: A total of 60 studies (2426 ankles) were included. Mean union rates for groups A to D were 93.2%, 95.5%, 93.0%, and 93.0%, respectively. Mean time to union was 10.4 weeks, 14.5 weeks, 12.4 weeks, and 14.4 weeks for groups A to D, respectively. Mean complication rates were 22.3%, 23.0%, 27.1%, and 28.7% for groups A to D, respectively. Reporting of outcome scores was insufficient to conduct meaningful analysis. CONCLUSION: Outcomes following ankle arthrodesis appear to be similar regardless of the duration of postoperative nonweightbearing, although the existing literature is insufficient to make definitive conclusions. Cite this article: Bone Joint J 2019;101-B:1256-1262.

Double arthrodèse de l'arrière pied associée à la libération postéro-médiale des parties molles dans le pied varus équin invétéré

Introduction : Les méthodes chirurgicales du pied varus équinirréductible sont variées. Le but de cette étude était d'évaluer les résultats de ce traitement par l'association simultanée de la double arthrodèse sous talienne et médio-tarsienne et la libération postéro-interne du pied. Patients et méthodes : Il s'agissait d'une étude rétrospective de 19 patients (19 pieds) opérés pour pied varus équins invétérés entre janvier 1990 et décembre 2002. L'âge moyen des patients était de 21 ans (13-38). La cause de la déformation était l'injection intra fessière avec déficit du grand nerf sciatique (n=15), la poliomyélite (n= 2), et le traumatisme(n=2). Le délai moyen entre le début de la lésion initiale et l'opération était 11ans (2 -26). Le tendon d'Achille était allongé. La désinsertion distale du muscle tibial postérieur était réalisée. Toutes les arthrodèses étaient fixées par des agrafes. La greffe osseuse n'a pas été réaliséeLes résultats étaient appréciés selon les critères de Angus et Cowell. Résultats : Le recul moyen était de 4,8 ans (2-10). Tous les patients ont été revus. La consolidation a été obtenue chez tous les patients dans un délai de trois mois. Les résultats globaux étaient bons (n=12), moyen (n=6), et mauvais (n=1). Il n'y avait ni échec de l'arthrodèse, ni nécrose du talus. Conclusion : La double arthrodèse associée à la libération postéro-interne dans le même temps opératoire permet une correction des déformations. Cette technique est fiable et ses résultats se maintiennent dans le temps

Workers' compensation is associated with worst clinical results after lumbar fusion / Compensação trabalhista é associada a piores resultados clínicos após artrodese lombar / Compensación laboral es asociada con los peores resultados clínicos después de artrodesis lumbar

ABSTRACT Objective: The objective of this study was to evaluate the association of clinical results with preoperative situation of worker compensation (WC) in patients submitted to spine surgery. Methods: This was a retrospective, comparative, single center study. Patients who underwent lumbar spine arthrodesis were included. The outcomes were pain scores (VAS), physical constraint (ODI) and quality of life (EQ-5D). Outcomes were analyzed before surgery and after surgery (minimum follow-up of six months and maximum of 12). Two groups were compared: individuals with or without WC at preoperative visit. Results: A total of 132 cases were analyzed (mean age 54 years and 51% female), 29 (22%) assigned to the WC group. The groups were matched for age, sex, and preoperative depression levels. In the preoperative period, the groups showed equal pain and physical constraint; however the CT group had lower quality of life (p=0.05). Although both groups showed improvement in clinical outcomes after surgery (p<0.05), worse scores were observed for the WC group compared to the non-WC group, respectively: VAS 4.9 vs. 3.2 (p=0.02), ODI 34.7 vs. 23.4 (p=0.002), and EQ-5D 0.56 vs. 0.75 (p=0.01). Conclusion: In this study it was possible to observe that WC is associated with worse clinical results following elective surgical treatment of the lumbar spine.

RESUMO Objetivo: O objetivo deste estudo foi avaliar a associação de resultados clínicos à situação pré-operatória de compensação trabalhista (CT) em pacientes submetidos à cirurgia de coluna. Métodos: Este estudo foi retrospectivo, comparativo e em único centro. Foram incluídos pacientes que passaram por artrodese da coluna lombar. Os desfechos clínicos foram escores de dor (EVA), restrição física (ODI) e qualidade de vida (EQ-5D). Os desfechos foram analisados antes e depois da cirurgia (acompanhamento mínimo de seis meses e máximo de 12). Dois grupos foram comparados: indivíduos sem ou com CT na visita pré-operatória. Resultados: No total foram analisados 132 casos (média de idade 54 anos e 51% do sexo feminino), sendo 29 (22%) do grupo com CT. Os grupos se mostraram pareados quanto a idade, sexo e nível de depressão pré-operatória. No pré-operatório os grupos se mostraram iguais quanto a dor e restrição física, porém, o grupo com CT apresentava qualidade de vida inferior (p = 0,05). Apesar de os dois grupos terem mostrado melhora nos desfechos clínicos após a cirurgia (p < 0,05), observaram-se piores escores para o grupo com CT comparado com grupo sem CT, respectivamente: EVA 4,9 vs. 3,2 (p = 0,02), ODI 34,7 vs. 23,4 (p = 0,002) e EQ-5D 0,56 vs. 0,75 (p = 0,01). Conclusão: No presente trabalho, foi possível observar que a CT está ligada a piores resultados clínicos após tratamento cirúrgico eletivo da coluna lombar.

RESUMEN Objetivo: El objetivo de este estudio fue evaluar la asociación de resultados clínicos con la condición preoperatoria de compensación laboral (CL) en pacientes sometidos a cirugía de columna. Métodos: Este estudio fue retrospectivo, comparativo y en un único centro. Se incluyeron pacientes sometidos a la artrodesis de la columna lumbar. Los parámetros clínicos analizados fueron puntuaciones de dolor (EVA), restricción física (ODI) y calidad de vida (EQ-5D). Esos parámetros se analizaron antes y después de la cirugía (seguimiento mínimo de seis meses y máximo de 12). Se compararon dos grupos: pacientes sin o con CL en la visita preoperatoria. Resultados: En total se analizaron 132 casos (promedio de edad 54 años y 51% del sexo femenino), siendo 29 (22%) del grupo con CL. Los grupos eran pareados en cuanto a edad, sexo y nivel de depresión preoperatoria. En el preoperatorio los grupos se mostraron iguales en cuanto al dolor y restricción física, pero el grupo con CL presentaba calidad de vida inferior (p = 0,05). Aunque los dos grupos hayan mostrado una mejora en los parámetros clínicos después de la cirugía (p < 0,05), se observaron puntuaciones más bajas en el grupo de CL en comparación con el grupo sin CL, respectivamente: EVA 4,9 vs. 3,2 (p = 0,02), ODI 34,7 vs. 23,4 (p = 0,002) y EQ-5D 0,56 vs. 0,75 (p = 0,01). Conclusión: En el presente estudio fue posible observar que la CL está vinculada a peores resultados clínicos después del tratamiento quirúrgico electivo de la columna lumbar.

Individual headless compression screws fixed with three-dimensional image processing technology improves fusion rates of isolated talonavicular arthrodesis.

BACKGROUND: Screw fixation is a typical technique for isolated talonavicular arthrodesis (TNA), however, no consensus has been reached on how to select most suitable inserted position and direction. The study aimed to present a new fixation technique and to evaluate the clinical outcome of individual headless compression screws (HCSs) applied with three-dimensional (3D) image processing technology to isolated TNA. METHODS: From 2007 to 2014, 69 patients underwent isolated TNA by using double Acutrak HCSs. The preoperative three-dimensional (3D) insertion model of double HCSs was applied by Mimics, Catia, and SolidWorks reconstruction software. One HCS oriented antegradely from the edge of dorsal navicular tail where intersected interspace between the first and the second cuneiform into the talus body along the talus axis, and the other one paralleled the first screw oriented from the dorsal-medial navicular where intersected at the medial plane of the first cuneiform. The anteroposterior and lateral X-ray examinations certified that the double HCSs were placed along the longitudinal axis of the talus. Postoperative assessment included the American Orthopaedic Foot & Ankle Society hindfoot (AOFAS), the visual analogue scale (VAS) score, satisfaction score, imaging assessments, and complications. RESULTS: At the mean 44-months follow-up, all patients exhibited good articular congruity and solid bone fusion at an average of 11.26 ± 0.85 weeks (range, 10 ~ 13 weeks) without screw loosening, shifting, or breakage. The overall fusion rates were 100%. The average AOFAS score increased from 46.62 ± 4.6 (range, 37 ~ 56) preoperatively to 74.77 ± 5.4 (range, 64-88) at the final follow-up (95% CI: -30.86 ~ -27.34; p < 0.001). The mean VAS score decreased from 7.01 ± 1.2 (range, 4 ~ 9) to 1.93 ± 1.3 (range, 0 ~ 4) (95% CI: 4.69 ~ 5.48; p < 0.001). One cases (1.45%) and three cases (4.35%) experienced wound infection and adjacent arthritis respectively. The postoperative satisfaction score including pain relief, activities of daily living, and return to recreational activities were good to excellent in 62 (89.9%) cases. CONCLUSIONS: Individual 3D reconstruction of HCSs insertion model can be designed with three-dimensional image processing technology in TNA. The technology is safe, effective, and reliable to isolated TNA method with high bone fusion rates, low incidences of complications.

[Arthrodesis of the First Metatarsophalangeal Joint by Locking Plate]. / Artrodéza I. metatarzofalangeálního kloubu úhlove stabilní dlahou.

PURPOSE OF THE STUDY The authors in their paper evaluate a group of patients who underwent arthrodesis of the first metatarsophalangeal joint using a locking plate. MATERIAL AND METHODS In the period 2010-2015, we performed surgery in 51 patients (56 forefeet), of which in 5 cases bilaterally and in 46 cases unilaterally, in 38 women and 13 men. The mean age was 57.8 years, the mean follow-up was 3.1 years. The indications for surgery were hallux rigidus in 23 patients, hallux valgus in 15 patients, hallux varus in 3 patients, and hallux erectus in 2 patients. In 4 patients the surgery was performed for valgus deformity associated with rheumatoid arthritis, 9 patients were indicated for a failure of the prior surgical intervention. In all 56 forefeet, the anatomic, low-profile titanium plate Variable Angle LCP 1st MTP Fusion Plate 2.4/2.7 was used. RESULTS According to Gainor s score the surgical outcomes were assessed as excellent in 46 patients who underwent surgery (90%), good in 4 patients (8%), fair in 1 patient (2%), and poor in 0 patient (0%). In 53 forefeet, the control radiographs showed solid bone union. In 2 patients and 3 forefeet, non-union of the arthrodesis occurred. In 2 forefeet, revision arthrodesis was performed, after which solid bone union followed. Malpositioned union was reported in 5 forefeet, of which in 4 cases into valgosity and in 1 case into dorsiflexion. DISCUSSION Numerous fixation materials can be used for arthrodesis of the first metatarsophalangeal joint. The use of the least stable Kirschner wires (cerclage) is being abandoned and substituted with a more stable fixation by screws, memory staples and locking plates. The achievement of excellent results requires proper positioning of the arthrodesis. Impingement syndrome between the big toe and the second toe can result in painful callosities formation, too large dorsiflexion can lead to a hallux hammertoe, with reduced big toe support function, to metatarsalgia. CONCLUSIONS The arthrodesis is indicated in patients with Grade III and IV hallux rigidus, with severe hallux valgus, hallux varus, and in patients in whom the previous surgeries failed. We tend to prefer stable arthrodesis. Fixation by anatomic LCP plate facilitates early rehabilitation, loading and early return to work and sports activities. Key words: arthrodesis, metatarsophalangeal joint, hallux rigidus, hallux valgus.

Evaluación funcional mediante la escala de oswestry en pacientescon artrodesis postero-lateral por canal lumbar estrecho / Functional evaluation by oswestry disability index in patients with postero-lateral arthrodesis for lumbar spinal stenosis

OBJETIVOS: Establecer la evolución funcional y condición neurológica con la escala de Oswestry en la biomecánica de la columna lumbar en pacientes que fueron intervenidos mediante descompresión neurológica y artrodesis posterolateral más estabilización con tornillos transpediculares por presentar diagnóstico de canal lumbar estrecho (CLE) en el Hospital Obrero N°1 de la ciudad de La Paz, Bolivia, durante las gestiones 2012 a 2014. Identificar los factores clínicos, socio-demográficos de pacientes en los cuales se realizó artrodesis en columna vertebral por canal lumbar estrechó. MÉTODOS: Se realizó un estudio retrospectivo, descriptivo, de corte transversal de pacientes en los cuales se realizó artrodesis postero-lateral por CLE en el servicio de ortopedia traumatología entre las gestiones 2012-2014, en el Hospital Obrero Nro1. Se evaluó 16 pacientes que cumplieron los criterios de inclusión. RESULTADOS: Según valoración de la escala de Oswestry: un 56% de pacientes tienen limitación funcional mínima y un 6% discapacidad a los 6 meses post operatorio. El género más afectado fue el femenino con un 57%, la edad promedio fue de 64 años, el tiempo previo al tratamiento quirúrgico fue mayor a 12 meses en el 63%, los niveles instrumentados más frecuentes fueron de L3-L5 y L5-S1 con un 25%. CONCLUSIONES: Se realizaron técnicas quirúrgicas descompresivas: laminectomia, foraminectomia con instrumentación. El índice de discapacidad de Oswestry permite valorar que la técnica fue efectiva debido a que los pacientes presentan una evolución funcional sin limitaciones en su vida cotidiana en la mayoría de los casos.

OBJECTIVES: To stablish the functional evolution and neurological condition through Oswestrydisability index (ODI)inthe biomechanics of the lumbar spine in patients who underwent neurological decompression and posterolateral arthrodesisand transpedicular screws stabilization by presenting lumbar spinalstenosis(LSS) in Obrero Hospital N° 1, La Paz city, Bolivia. To identify clinical, social and demographic factors of patients with degenerative lumbar spinal stenosis in which postero-lateral arthrodesis was performed. METHODS: A retrospective, descriptive and cross-sectional study between 2012 and 2014 was conducted. Patients who were treated with postero-lateral arthrodesis for lumbar spinal stenosis, in the traumatology service at Obrero Hospital in La Paz city were considered. We evaluated 16 patients who met the inclusion criteria. RESULTS: According to Oswestrydesability index, 56% of the patients have minimal functional limitation and 6% of disability at 6-month postoperative. The most affected gender were females with 57%, the average age was 64 years, prior time to surgical treatment was more than 12 months in 63%, and the most frequent instrumented levels were L3-L5 and L5-S1 with 25%. CONCLUSIONS: We performed decompressive surgical techniques: laminectomy, foraminotomy with instrumentation. Oswestry disability index helped to determine the applied techniqueswere effective. In most cases, patients displayed a functional evolution without limitations in their daily lives.

The Use of Allostem in Subtalar Fusions.

Subtalar arthrodesis is the mainstay for treatment of a variety of hindfoot problems associated with arthritis, however with an unpredictable if not high rate of nonunion. This article covers the use of adipose-derived stem cells as an adjunct or alternative to autologous or other bone grafting materials. Promising development and encouraging data exist with respect to the use of adipose-derived mesenchymal stem cells for bone arthrodesis, which is discussed in more detail in the article.

Prevalencia de úlceras por presión en pacientes sometidos a artrodesis de columna / Prevalence of pressure ulcers in patients undergoing an arthrodesis spine

Objetivos: Identificar la incidencia de úlceras por presión (UPP) en el quirófano en pacientes sometidos a artrodesis de columna realizadas en el intervalo de 2 años. Material y métodos: Diseño descriptivo, trasversal retrospectivo. Revisión de historias clínicas. Resultados: Se valoraron 269 pacientes, 52% mujeres, de una media de edad de 58,7 años. Las posiciones más frecuentes fueron decúbito supino y decúbito prono (34% ambas). La prevalencia de UPP fue del 14%, con un 51,4% de grado II, y la localización más frecuente fue tórax y frente. La mayor frecuencia de aparición fue a partir de las 4 horas de intervención, pero no hallamos relaciones significativas entre la aparición de úlceras por presión y otras variables. Conclusiones: Es necesario llevar a cabo estudios de intervención para prevenir UPP en el área quirúrgica, debido a que existe poca bibliografía al respecto. Por otro lado, la alta incidencia hallada nos hace plantearnos la necesidad de aumentar las medidas preventivas por parte de enfermería

Objectives: Identify the incidence of pressure ulcers (PU) in surgery in patients undergoing spinal fusion performed in the range of 2 years. Material and methods: Descriptive, transversal and retrospective design. Review of medical histories. Results: 269 patients were evaluated, 52% were women and the average age of 58.7 years. The most frequent were supine and prone positions (34% both). PU prevalence was 14%, with 51.4% grade II, the most frequent location was chest and forehead. The highest frequency of occurrence was from 4 hours intervention, but we have not significant relationships between pressure ulcers and other variables. Conclusions: It is necessary to carry out intervention studies to prevent PU in the surgical area, because there is little literature. On the other hand the high incidence found begs the need to increase preventive measures by nurses

Reliability of the Radiographic Sagittal and Frontal Tibiotalar Alignment after Ankle Arthrodesis.

BACKGROUND: Accurate measurement of the tibiotalar alignment is important in radiographic outcome assessment of ankle arthrodesis (AA). In studies, various radiological methods have been used to measure the tibiotalar alignment leading to facultative misinterpretation of results. However, to our knowledge, no previous study has investigated the reliability of tibiotalar alignment measurement in AA. We aimed to investigate the reliability of four different methods of measurement of the frontal and sagittal tibiotalar alignment after AA, and to further clarify the most reliable method for determining the longitudinal axis of the tibia. METHODS: Thirty-eight weight bearing anterior to posterior and lateral ankle radiographs of thirty-seven patients who had undergone AA with a two screw fixation technique were selected. Three observers measured the frontal tibiotalar angle (FTTA) and the sagittal tibiotalar angle (STTA) using four different methods. The methods differed by the definition of the longitudinal tibial axis. Method A was defined by a line drawn along the lateral tibial border in anterior to posterior radiographs and along the posterior tibial border in lateral radiographs. Method B was defined by a line connecting two points in the middle of the proximal and the distal tibial shaft. Method C was drawn "freestyle"along the longitudinal axis of the tibia, and method D was defined by a line connecting the center of the tibial articular surface and a point in the middle of the proximal tibial shaft. Intra- and interobserver correlation coefficients (ICC) and repeated measurement ANOVA were calculated to assess measurement reliability and accuracy. RESULTS: All four methods showed excellent inter- and intraobserver reliability for the FTTA and the STTA. When the longitudinal tibial axis is defined by connecting two points in the middle of the proximal and the distal tibial shaft, the highest interobserver reliability for the FTTA (ICC: 0.980; CI 95%: 0.966-0.989) and for the STTA (ICC: 0.997; CI 95%: 0.996-0.999) is provided. Intergroup analysis for FTTA measurements revealed a statistically significant difference between the method in which the lateral border of the tibia was used to determine the longitudinal axis of the tibia, and the other methods in which the longitudinal axis was defined by bisecting the tibia. CONCLUSIONS: When the longitudinal axis of the tibia is defined by connecting two points in the middle of the proximal and the distal tibial shaft for measuring the FTTA and STTA, the most favorable interobserver reliability is provided. Therefore, this method can be recommended for evaluating the frontal and the sagittal alignment on anterior to posterior and lateral radiographs after ankle arthrodesis.

[Subtalar arthrodesis]. / Die Arthrodese des Subtalargelenks.

OBJECTIVE: Realignment and stabilization of the hindfoot by subtalar joint arthrodesis. INDICATIONS: Idiopathic/posttraumatic arthritis, inflammatory arthritis of the subtalar joint with/without hindfoot malalignment. Optional flatfoot/cavovarus foot reconstruction. CONTRAINDICATIONS: Inflammation, vascular disturbances, nicotine abuse. SURGICAL TECHNIQUE: Approach dependent on assessment. Lateral approach: Supine position. Incision above the sinus tarsi. Exposure of subtalar joint. Removal of cartilage and breakage of the subchondral sclerosis. In valgus malalignment, interposition of corticocancellous bone segment; in varus malalignment resection of bone segment from the calcaneus. Reposition and temporarily stabilization with Kirschner wires. Imaging of hindfoot alignment. Stabilization with cannulated screws. Posterolateral approach: Prone position. Incision parallel to the lateral Achilles tendon border. Removal of cartilage and breakage of subchondral sclerosis. Medial approach: Supine position. Incision just above and parallel to the posterior tibial tendon. Removal of cartilage and breakage of subchondral sclerosis. Stabilization with screws. POSTOPERATIVE MANAGEMENT: Lower leg walker with partial weightbearing. Active exercises of the ankle. After a 6­week X­ray, increase of weightbearing. Full weightbearing not before 8 weeks; with interpositioning bone grafts not before 10-12 weeks. Stable walking shoes. Active mobilization of the ankle. RESULTS: Of 43 isolated subtalar arthrodesis procedures, 5 wound healing disorders and no infections developed. Significantly improved AOFAS hindfood score. Well-aligned heel observed in 34 patients; 5 varus and 2 valgus malalignments. Sensory disturbances in 8 patients; minor ankle flexion limitations. Full bone healing in 36 subtalar joints, pseudarthrosis in 4 patients.

A Multicenter, Retrospective Study of Early Weightbearing for Modified Lapidus Arthrodesis.

The modified Lapidus arthrodesis is a long-established surgical technique for management of hallux valgus that provides reproducible results and quality patient outcomes. The data from 367 consecutive patients undergoing unilateral modified Lapidus arthrodesis from January 1, 2007 to December 31, 2008 at participating centers were retrospectively evaluated. The included patients were categorized into early weightbearing (≤ 21 days) and delayed weightbearing (> 21 days) groups. A total of 24 nonunions (6.5%) were identified, with 13 (7.1%) in the early weightbearing group and 11 (6.0%) in the delayed weightbearing group. To date, the present study is the largest multicenter investigation to evaluate early weightbearing after modified Lapidus arthrodesis and the only large study to directly compare early and delayed weightbearing. The findings of the present study have shown that early weightbearing for modified Lapidus arthrodesis does not increase the risk of nonunion when evaluating various fixation constructs.

Forefoot Deformity in Rheumatoid Arthritis: A Comparison of Shod and Unshod Populations.

UNLABELLED: All reported rheumatoid arthritis (RA) forefoot deformities in the literature thus far have arisen from shoe wearing populations. Our aim in this study was to compare hallucal deformities seen in a shod population with an unshod population. A population comparison was undertaken in 2 specialized foot and ankle units, one in India and one in the United Kingdom. In the shod population, there was 1 hallux varus deformity, 10 without hallucal deformity, and 90 hallux valgus deformities. In contrast, in the unshod population, there were 19 hallux varus deformities and 6 hallux valgus deformities. There was great variability in the lesser toe deformity seen. In the shod population, it was most common to see dorsal subluxation or dislocation, with the fifth toe in a varus position. In the unshod population, the most common lesser toe deformity seen was varus deviation or dislocation. Instability of the metatarsophalangeal joint in the rheumatoid foot predisposes it to significant deformity. In the non-shoe wearing population, intrinsic muscle forces and weight bearing forces are the most likely determinants of the deformity, with hallux varus being a more common presenting problem. In the shod population, the external forces of shoe wear dictate the direction of deformity. LEVELS OF EVIDENCE: Prognostic, Level III: Case control study.

Radiographic and functional outcomes following bilateral ankle fusions.

BACKGROUND: Ankle arthrodesis is considered to be a well-accepted technique for end-stage ankle arthritis. Our purpose was to evaluate outcomes of patients with bilateral ankle arthrodeses with attention to radiographic and functional outcomes. METHODS: Medical records of 31 patients were reviewed from 1977 through 2007. All patients had 1 year of clinical follow-up after their contralateral ankle arthrodesis, with an average follow-up of 11.2 years following the initial arthrodesis. Pertinent patient demographics and information pertaining to the operative procedure, complications, and subsequent adjacent joint fusions was collected. Radiographs were reviewed for time to fusion and adjacent joint arthritis. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot scale. RESULTS: Ten females and 21 males underwent bilateral ankle fusions at an average age of 57 years at the time of the initial fusion. The contralateral fusion occurred on average 3.1 years following the initial fusion. Radiographic fusion occurred 12 weeks following the initial fusion and 14 weeks following the contralateral fusion. There was a significant increase (P = .0001) in the average AOFAS score postoperatively in both ankles. The average FAAM score at last follow-up was 70. Adjacent joint arthritis developed in the majority of patients; however, most of the patients were free from adjacent fusions and reported their function as "normal" or "nearly normal" at last follow-up. CONCLUSION: Bilateral ankle arthrodesis was an acceptable treatment option for patients with bilateral, end-stage ankle arthritis. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Artrodesis sin fusión ósea con clavo modular intramedular para revisión de prótesis total de rodilla infectada / Arthrodesis without bone fusion with an intramedullary modular nail for revision of infected total knee arthroplasty

Objetivo. Evaluar los resultados de la fijación de rodilla sin fusión ósea, con clavo intramedular e interposición de cemento. Material y métodos. Estudio retrospectivo de 29 prótesis total de rodilla infectadas con datos recogidos prospectivamente y seguimiento medio de 4,2 años (3-5). Resultados. Las complicaciones fueron 2 infecciones recurrentes, una fractura periimplante y una erosión cortical en la punta del componente femoral, siendo todas revisadas con buen resultado. La dismetría media fue 0,8 cm, con 24 < 1 cm. Veinticinco pacientes no referían dolor. El valor medio de WOMAC-dolor fue 86,9, WOMAC-función 56,4, SF12-físico 45,1, y SF12-mental 53,7. Cuatro pacientes precisaron andador y solo 2 eran dependientes para actividades diarias. Conclusiones. El clavo Endo-Model Link® es un efectivo método de fijación de rodilla, restaurando la alineación del miembro y adecuada longitud del mismo (AU)

Objective. To evaluate the outcome of knee fixation without bone fusion using an intramedullary modular nail and interposed cement. Material and methods. Retrospective study of 29 infected total knee arthroplasties with prospective data collection and a mean follow-up of 4.2 years (3-5). Results. Complications included 2 recurrent infections, 1 peri-implant fracture, and 1 cortical erosion due to the tip of the femoral component. All of these were revised with successful results. The mean limb length discrepancy was 0.8 cm, with 24 < 1 cm. Twenty-five patients reported no pain. The mean WOMAC-pain was 86.9, WOMAC-function 56.4, SF12-physical 45.1, and SF12-mental 53.7. Four patients needed a walking frame, and only two were dependent for daily activities. Conclusions. The Endo-Model Link nail is an effective method for knee fixation that restores the anatomical alignment of the limb with adequate leg length (AU)

Update on the surgical treatment for rheumatoid arthritis of the wrist and hand.

Surgical procedures for the treatment of rheumatoid arthritis are aimed at restoring function and decreasing pain. Over the past four decades multiple procedures have been described in the management of early and late disease. This article will review the most common forms of surgery used in the treatment of rheumatoid arthritis.

Factors associated with longer length of hospital stay after primary elective ankle surgery for end-stage ankle arthritis.

BACKGROUND: Longer length of stay in the hospital after elective surgery results in increased use of health-care resources and higher costs. Improved perioperative care permits many foot and ankle surgical procedures to be performed as day surgery. This study determined perioperative factors associated with a longer length of stay after elective total ankle replacement or ankle arthrodesis. METHODS: Data were prospectively collected on patients who underwent open or arthroscopic ankle fusion or total ankle replacement for end-stage ankle arthritis at our institution from 2003 to 2010. Univariate and multivariable generalized linear regression models with gamma distribution and log link function were conducted with use of the length of the hospital stay as the dependent variable and preselected risk factors of age, sex, physical and mental functional scores, comorbid factors, American Society of Anesthesiologists grade, body mass index, type of surgery, duration of surgery, and surgery day of the week as the independent variables. RESULTS: This study included 343 patients with a median length of stay of seventy-five hours (interquartile range, fifty-two to ninety-seven hours). With use of regression analyses, the variables of age, female sex, higher American Society of Anesthesiologists grade, multiple medical comorbidities, rheumatoid arthritis, lower Short Form-36 Physical Component Summary and General Health domain scores, and open surgery were significantly associated with increased length of stay. Conversely, the variables of obesity, Short Form-36 Mental Component Summary score, surgery day of the week, and surgical duration were not associated with length of stay. Two predictive models of the length of stay were developed: one included only patient-related factors, and the other included patient and surgery-related factors. CONCLUSIONS: The patients who are identified with a higher risk of a longer length of stay may warrant better education and more focused perioperative care when designing care pathways and allocating health-care resources.

Procedimiento de Sauvé-Kapandji en los trastornos de la articulación radiocubital distal / Sauvé-Kapandji procedure in distal radioulnar joint disorders

Objetivo. Evaluar los resultados funcionales y subjetivos del procedimiento de Sauvé-Kapandji como tratamiento de los trastornos de la articulación radiocubital distal. Material y método. Realizamos un estudio retrospectivo de 27 pacientes sometidos a la técnica de Sauvé-Kapandji desde enero de 2001 a marzo de 2012. Analizamos la etiología, edad, sexo, lateralidad, balance articular, signos radiográficos de degeneración articular y varianza cubital. Para la evaluación postoperatoria se utilizó la escala de valoración de muñeca de la Clínica Mayo y el cuestionario DASH. El seguimiento medio fue de 24 meses (6-48 meses). La edad media fue de 47,2 años. El 66,7% fueron mujeres y el 55,5% lado dominante. Resultados. Al año de la cirugía 16 casos presentaron dolor leve o ausente (59,2%), 8 casos moderado (29,6%) y 3 casos severo (11,1%). La pronosupinación pasó de un promedio preoperatorio de 96,8° a 136,4° postoperatorios, resultando esta diferencia estadísticamente significativa (prueba de Wilcoxon). La relación radiocubital pasó de un promedio preoperatorio de +2,6 mm a −0,39 mm postoperatorios. La recuperación laboral sin limitación fue posible en el 48%. Se consiguió una fuerza de prensión del 50,6% respecto a la muñeca contralateral. Conclusiones. La técnica de Sauvé-Kapandji podría evitar complicaciones frecuentes de otros procedimientos como la migración carpiana cubital. Nuestro estudio coincide con la literatura en los buenos resultados respecto al rango articular con aceptable mejoría del dolor respecto al estado previo, pero también demuestra la frecuente pérdida de fuerza de prensión e inestabilidad del muñón cubital proximal (AU)

Objective: To evaluate the functional and subjective results of the Sauvé-Kapandji procedure as a treatment for distal radioulnar joint disorders. Material and method: A retrospective study was conducted on 27 patients treated using the Sauvé-Kapandji technique from January 2001 to March 2012. The aetiología, age, sex, laterality, articular movement, radiographical signs of joint degeneration, and cubitus varus, were analysed. The Mayo Clinic wrist assessment scale and the DASH questionnaire were used for the postoperative evaluation. The mean follow-up was 24 months (6-48 months). The mean age was 47.2 years, with 66.7% females, and 55% the dominant side. Results: At one year after surgery, 16 cases had mild or no pain (59.2%), 8 cases with moderate (29.6%) and 3 cases with severe pain (11.1%). The pronation-supination went from a pre-operative average of 96.8◦ to 136.4◦ postoperative, operatorios, which was a significant statistical difference (Wilcoxon test). The radioulnar ratio went from an pre-operative average of +2.6 mm to −0.39 mm postoperative. Full functional recovery was observed in 48%. A grip strength of 50.6%, compared to the contralateral wrist was achieved. Conclusions: The Sauvé-Kapandji technique could avoid the complications common in other procedures, such as cubital-carpal migration. Our study agrees with that in the literature with good results as regards the range of joint movement, with an acceptable improvement in pain compared to the previous stage, but it also demonstrates the frequent loss of grip strength and instability of the proximal radio-ulnar joint (AU)

High-grade spondyloretrolisthesis in a 12-year-old girl with neurofibromatosis type 1: a case report and literature review.

Neurofibromatosis (NF) type 1 is characterized by several skin, endocrine, central nervous system and musculoskeletal manifestations, spine deformities being the most common, affecting up to 64% of patients. Thoracic kyphoscoliosis is the most common deformity observed; however, high-grade spondylolisthesis and dural defects such as dural ectasia can also be found. The aim of this study is to describe a case of high-grade spondyloretrolisthesis in an NF-1 patient, associated with dural ectasia and extensive lumbar laminectomies, and to discuss our management and review the current literature on this controversial topic. A 12-year-old girl with NF-1 who had undergone extensive lumbar laminectomies in an outside facility presented to our emergency department complaining of back pain and lower limbs upper motor neuron symptoms. Image studies showed a high-grade lumbar spondyloretrolisthesis associated with dural ectasia. The first step of treatment was spine immobilization using a Boston brace. An anterior approach was used, and an L2 corporectomy was performed, using a Moss type cage between L1 and L3 with an instrumented arthrodesis and autologous bone graft for stabilization purposes. The second step planned was a posterior approach for arthrodesis and instrumentation, but after an extensive discussion with the parents and the patient, the parents did not agree to the procedure planned for the patient. A brace was used for 1 year while rehabilitation was performed. At the 1-year follow-up, there was a 70° kyphosis at the thoracolumbar junction but it was clinically stable, with an acceptable sagittal balance. Dural ectasia is not a common finding in children with NF-1; however, it should be identified as its presence may predispose to spine instability and as a consequence the development of a high-grade spondyloretrolisthesis. Even though a few cases have been reported, we believe that it is important to consider the option of a double approach to achieve a better correction in both planes and a good outcome. If an extensive laminectomy is involved, it is mandatory to perform a posterior fusion and instrumentation.

El raquis no se libró de las leyes del mercado. La artrodesis con autoinjerto sigue siendo el procedimiento tipo / The spinal column is not free of market laws. Arthrodesis with an autogenous graft continues to be the procedure-type

No disponible